Praxis Medical Insights

Introduction to Treatment

Non-operative management is the appropriate initial treatment for degenerative cervical disc height and facet arthropathy, with 75-90% of patients achieving symptomatic improvement through conservative measures 1

The American College of Physicians recommends beginning with acetaminophen (paracetamol) in doses of up to 4g daily, with ibuprofen as an alternative at 1.2g daily if acetaminophen fails to provide adequate relief 2
For insufficient relief with initial NSAID therapy, options include increasing ibuprofen to 2.4g daily, adding acetaminophen to ibuprofen, or switching to alternative NSAIDs such as diclofenac or naproxen 2
Consider gastroprotective agents in patients at high risk for NSAID-induced gastrointestinal complications 2

Physical therapy focusing on core strengthening and flexibility exercises is a cornerstone of initial treatment, with statistically significant clinical improvement for patients with cervical radiculopathy 1, 2
Acupuncture may be considered as an adjunct to conventional therapy 2
For persistent facet-related pain, conventional radiofrequency ablation of the medial branch nerves may be considered when previous diagnostic or therapeutic injections have provided temporary relief 2

The initial 6-8 weeks of treatment should involve conservative management with medications and physical therapy, beginning with acetaminophen and/or NSAIDs, and initiating physical therapy focusing on cervical strengthening and flexibility 1, 2
For persistent symptoms (2-3 months), consider epidural steroid injections for radicular pain 1
For refractory symptoms (>6 months), surgical intervention may be considered after at least 6 months of failed comprehensive conservative management 2

Both anterior cervical discectomy (ACD) and anterior cervical discectomy with fusion (ACDF) are equivalent treatment strategies for 1-level disease with regard to functional outcomes, according to the North American Spine Society 3, 4
ACDF may achieve more rapid reduction of neck and arm pain compared to ACD with a reduced risk of kyphosis 3, 4
For 2-level cervical disc degeneration, anterior cervical plating (ACDFI) is recommended over ACDF to improve arm pain, as suggested by the American Association of Neurological Surgeons 3, 4
Cervical arthroplasty is recommended as an alternative to ACDF in selected patients for control of neck and arm pain, based on guidelines from the Congress of Neurological Surgeons 3, 4

Regular monitoring for NSAID-related adverse effects is essential, particularly gastrointestinal and cardiovascular complications 2
MRI findings must always be correlated with clinical symptoms, as false positives and false negatives are common in cervical spine imaging, as noted by the American College of Radiology 1
Chemical denervation is not recommended for routine care of chronic non-cancer pain 2
For patients with neuropathic pain components, consider tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors, starting at low doses and titrating gradually, as recommended by the American Academy of Neurology 2

At 12 months, physical therapy can achieve comparable clinical improvements to surgical interventions, though surgical approaches may provide more rapid relief (within 3-4 months) 1
Surgical outcomes for relief of arm pain range from 80% to 90% with either anterior or posterior approaches 1